COVID-associated rhinocerebral mucormycosis: a retrospective analysis of presentation and outcomes.

OBJECTIVES: To comprehensively analyse the disease presentation and mortality of COVID-associated rhino-orbito-cerebral mucormycosis. METHODS: A retrospective analysis of the demographics, clinical and radiographic findings was performed. A binary logistic regression analysis was performed to examine the survival of patients with mucormycosis from hypothesised predictors. RESULTS: A total of 202 patients were included in this study. Statistical significance was demonstrated in the predilection to the male gender, recent history of SARS-COV-2, history of use of corticosteroid and hyperglycemia in this cohort of CAM. The mortality rate was 18.31%. Advanced age, raised HbA1c and intra-orbital extension were found to be predictors adversely affecting survival. CONCLUSION: Early diagnosis, aggressive surgical therapy, early and appropriate medical therapy can help improve outcomes. LEVEL OF EVIDENCE: Level 4.

Incidence of COVID-19-Associated Mucormycosis in COVID-19 Patients after Discharge from the COVID-19 Hospital.

Background: There are studies available on the prevalence of coronavirus disease 2019 (COVID-19)-associated mucormycosis (CAM) in hospitalized patients but not on the incidence of CAM in post-discharge patients. The aim of our study was to find the incidence of CAM in the patients discharged from a COVID hospital. Material and Methods: Adult patients with COVID discharged between March 1, 2021 and June 30, 2021 were contacted and enquired about sign and symptoms of CAM. Data of all included patients were collected from electronic records. Results: A total of 850 patients responded, among which 59.4% were males, 66.4% patients had co-morbidities, and 24.2% had diabetes mellitus. Around 73% of patients had moderate to severe disease and were given steroids; however, only two patients developed CAM post discharge. Conclusion: The incidence of CAM post discharge was low in our study, which could be attributed to protocolized therapy and intensive monitoring.

Single-Stage Reconstruction of Maxillectomy and Midfacial Defects in Cases of Covid Associated Mucormycosis.

Objective: To advocate a single stage reconstruction in cases of maxillectomy and midfacial defects operated for covid associated mucormycosis to enable a favorable overall outcome within a shorter duration in terms of survival, quality of life, speech, deglutition and aesthetics. Method: In our series of six patients with signs and symptoms suggestive of covid associated mucormycosis with diabetes as a predisposing factor had undergone Contrast enhanced CT and MRI with biopsy confirming the diagnosis, were then subsequently posted for resection and reconstruction depending upon extent of disease and defect left behind. Out of six, three were revision cases and the other three were primary cases. All had undergone single stage reconstruction using free flap (5/6) and pedicle (1/6) after intra-operative margins and distal most part of recipient vessels was found negative for mucormycosis on histopathology. Post-operative Liposomal Amphotericin B with Oral Posaconazole along with antibiotics and supportive treatment were given and were then followed up. Results: All the cases have complete flap survival after a mean follow-up of 90 days with no recurrence of mucormycosis. We had a survival rate of 100% with patients having good quality of life, speech, deglutition and acceptable aesthetical outcome. Conclusion: Stepping up on the reconstruction ladder to provide a single stage management in patients of covid associated mucormycosis by adequate surgical debridement, intraoperative negative margins on histopathology and subsequent reconstruction using autologous flaps is the need of the hour to provide within a shorter duration, favourable overall outcome in terms of survival, quality of life, speech, deglutition and aesthetics. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-022-03121-1.

COVID-19, Diabetes and Steroids: The Demonic Trident for Mucormycosis.

Coronavirus disease 2019 (COVID-19) has been found to be associated with mucormycosis in few parts of the world, especially India. It is important to look for reasons for this upsurge of cases so that other countries may take proper steps to prevent it. A prospective clinico-demographic study was conducted in SMS Medical College, Jaipur, India from April to May 2021. All patients (235) with COVID associated mucormycosis (CAM) were studied in detail with reference to their diabetic status and steroid intake during treatment of COVID-19. Steroid usage was in 84.3% of patients with methylprednisolone being the most commonly used steroid (66.8%). Majority of the patients had taken steroids for 7-14 days. Diabetes was found in 204 patients and 42.1% of patients were newly diagnosed during/after COVID-19 treatment. The HbA1c levels of diabetic patients ranged from 6.0% to 16.3%. This is perhaps the biggest study in the world shows that the triad of COVID-19, diabetes and steroid usage is a major contributing factor towards mucormycosis. Proper steps should be taken to prevent CAM.

Prosthetic Rehabilitation of Nose After Partial Rhinectomy in a Patient Affected with Mucormycosis: A Case Report.

Mucormycosis is a fungal infection commonly seen in Indian population, in which aggressive surgical intervention to cut away the infected tissue becomes necessary. This may cause disfigurement and leave open wounds which requires prosthetic replacement for psychological benefit and also protect the inner soft tissues of the patient which are exposed to the foreign bodies. Mucormycosis has shown a sudden surge in recent times associated with patients affected by Covid-19. It is a rare but serious complication which can cause loss of eye, nose and associated structures leaving the patient disfigured. The aim of this case report is to describe an economic but effective nonsurgical treatment option to restore the facial defect using acrylic resin baseplate to enhance retention by using the available undercuts and was packed using silicone material. The prosthesis was retained mechanically and omitted the use of any retentive aids such as the use of spectacles or implants.

Sublabial Approach Versus Modified Denker's Procedure: A Comparative Study of Pre-maxillary Tissue Clearance in Covid-Associated Mucormycosis.

To compare the efficacy of the sublabial and modified Denker's procedure in clearance of fungal disease from the anterior wall of maxilla and the pre-maxillary area i.e. the difficult areas of maxillary sinus. A prospective observational study was conducted over a period of 2 months (April 21-June 21) in the ENT department of Sawai Man Singh hospital, Jaipur. All the patients with clinical involvement of the premaxilla or the cheek abutting the anterior wall of maxilla were included in the study population. Cases matched in both groups were subjected to debridement either by the sublabial or the modified denker's approach. Outcomes were measured by assessing the daily CRP values, post-operative DNE every 3 days after pack removal, and imaging at the end of 1 month. Repeat biopsies were performed in patients that still had persistent symptoms after getting operated on. 16 of the 60 patients (26.6%) operated on by the endoscopic approach showed evidence of residual disease on follow-up whereas only 5 patients (9.6%) in the other category had a similar outcome. Most of the recidivism was seen in the anterior maxilla. Lower rates of complications were found following debridement by the sublabial approach. Since the sublabial approach is the most direct approach for the key areas of fungal involvement of maxillary sinus, it is recommended over the modified Denker's procedure for disease clearance from pre maxilla and the anterior wall of maxillary sinus. This view is also supported by the lower rates of complications encountered following the former.

Management of Covid Associated Mucormycosis of Mandible: A Mountain Beneath a Molehill-A Lesson Learnt.

The opportunistic infection of post-Covid associated mucormycosis has been reported globally; however, it has reached alarming proportions in India. Mucormycosis of the mandibular region is rare, and only a few cases have been reported to date. Covid associated mucormycosis has not been reported in the literature before, and we are the first to report them. We report two patients who presented with tooth loosening with pus discharge a few weeks following recovery from Covid infection. After tooth extraction adjacent necrotic bony specimen was sent for calcofluor potassium hydroxide mount, which was found positive for broad pauciseptate hyphae. Although CT scan imaging demonstrated the involvement of a mandible segment, we found a much more extensive involvement in both cases during resection. There was intramedullary spread of the mucormycosis throughout the inferior alveolar canal, with pus discharge and foul odor. The management of covid associated mandibular mucormycosis consists of surgical debridement with antifungal therapy and control of the underlying disease. It became challenging because the radiological extent of the disease was different from the definite clinical extension of the lesion found during surgery. The authors recommend surgeons adopt a flexible approach during surgery to plan resection depending on the clinical judgment and not rely entirely on CT scans. And the reconstruction of the mandible will follow as per the extent of excision.

Neem and Turmeric in the management of Covid Associated Mucormycosis (CAM) derived through network pharmacology.

Mucormycosis or 'Black Fungus' has been known to target immunocompromised individuals even before the emergence of COVID-19. Nevertheless, the present circumstances provide the best opening for Covid Associated Mucormycosis (CAM), as the global pandemic is engulfing a large part of human population making them immunocompromised. This drastic increase in Mucormycosis infections has to be addressed as early as possible. There is a growing tendency of relying upon herbal drugs that have minimal side effects and does not compromise our immune system. Recently, the concept of network pharmacology has grabbed the attention of modern science, especially advanced medical sciences. This is a new discipline that can use computational power to systematically catalogue the molecular interactions between botanical formulations and the human body. In this study, Neem and Turmeric was considered as the target plants and an attempt was made to reveal various aspects through which phytocompounds derived from them may effectively manage CAM menace. We have taken a step-by-step approach for identifying the target proteins and ligands associated with Mucormycosis treatment. Functional network analysis and Molecular docking approaches were applied to validate our findings. Quercetin derived from both Neem and Turmeric was found to be one of the main phytocompounds working against Mucormycosis. Along with that, Caffeic acid, Curcumin, Kaempferol, Tetrahydrocurcumin and Myricetin also play a pivotal role in fighting against Black-Fungus. A thorough analysis of our result suggested a triple-front attack on the fungal pathogens and the approaches are necrosis inhibition, iron chelation and immuno-boosting.Communicated by Ramaswamy H. Sarma.

Post-COVID Mucormycosis Involving Mandible: A Rare Phenomenon.

Mucormycosis is a fungal disease involving predominantly the paranasal sinuses and further spreading to the orbit and cerebral regions. It does rarely affect the pulmonary region and gastrointestinal regions. This disease is seen more in a very serious state, where the tissues undergo necrosis and cause huge morbidity and, in some cases, end up being fatal. The disease was common in individuals with an immune-compromised state, thus more commonly presenting in individuals with uncontrolled diabetes. The disease is usually acquired through coming into contact with spores of the fungus Mucormycetes through the nose, and the fungi invade the paranasal regions, colonize, and spread locally with angio-invasion and relying on host ferritin for survival, thereby causing tissue necrosis. The incidence of mucormycosis had increased considerably post-COVID-19 due to host immune factors. This fungus commonly spreads from paranasal regions to the cranial direction through orbit. The spread is rapid, thus needing early medical and surgical intervention. The spread of infection from the paranasal regions to the caudally placed mandible is very rarely seen. In this paper, we present three cases of mucormycosis spreading caudally and involving the mandibular regions.

Interpreting Mortality in COVID Associated Mucormycosis (CAM): A Learning Experience from a Tertiary Care Centre

Mucormycosis has emerged as an important fungal infection with high associated mortality rates. Mucormycosis causes devastating angio-invasive fungal infections, primarily in patients with underlying risk factors. The prevalence of mortality associated with invasive Mucormycosis is high (>30-50%), with 90% mortality contributed by disseminated disease. Sudden rise in Mucormycosis cases during the COVID-19 pandemic came as a surprise to all. Lowered immunity due to COVID and associated conditions like diabetes, made the population susceptible to this dreaded disease. This disease led to both increase in morbidity and mortality among the general population. Aim of the Study: To interpret in detail the causes of mortality of patients presenting with COVID Associated Mucormycosis (CAM-19) at AIIMS Patna between May-November, 2021. Material(s) and Method(s): An observational study of all patients who were treated for mucormycosis during the period of May 2021-Nov 2021 in ENT Department, AIIMS, Patna. During the period of study, 219 patients of Rhino-Orbital-Cerebral Mucormycosis (ROCM) were admitted for treatment. Five patients had gone on Leave Against Medical Advice (LAMA). So, 214 patients were included in the study. Result(s): Among the 214 patients, 165 patients were treated surgically through both endoscopic and open approaches along with antifungal therapy management. 41 patients died during the hospital course of the treatment. The mortality rate of ROCM stood at 19.15% in our series. Pulmonary Mucormycosis had high mortality (100%). Diabetes is the most common risk factor. Multiple co-morbidities and extensive intracranial involvement had a strong association with mortality. Conclusion(s): The advanced stage of ROCM was associated with more deaths. Our series mortality rate of 19.15% is lower than most of the other documented mortality rates. Our results support that early aggressive surgical approach, antifungal therapy and multidisciplinary approach has reduced the mortality.Copyright © 2022 Indian Medical Association. All rights reserved.

Various Treatment Modalities in COVID-19 Associated Facial Mucormycosis and the Need for its Surgical Management: A Systematic Review.

Introduction: Mucormycosis emerged as a wildfire in post-covid-19 infected patients. Most frequently involved sites of mucormycosis are rhino-orbital, rhino-sinusal and rhino-orbito-cerebral. The hallmark sign of mucormycosis is tissue necrosis, which is often a late sign. The fatality rate of mucormycosis is 46% globally. Despite early aggressive combined surgical and medical therapy, the prognosis of mucormycosis is poor. Methods: We searched the electronic database of PubMed, web of science, Embase, Scopus and Google Scholar from Jan 2020 until December 2021 using keywords. We retrieved all the granular details of original research articles, case reports/series of patients with rhino-orbito-cerebral mucormycosis (ROCM), and COVID-19 reported worldwide. Subsequently, we analyzed the patient characteristics, associated comorbidities, location of mucormycosis, treatment given and its outcome in people with COVID-19. (Prospero registration-CRD42021256830, June 4, 2021). Results: Overall, 544 rhino-orbito-cerebral mucormycosis patients were included in our review with a history of Covid-19 infection. Out of which 410 patients had diabetes mellitus which has proven to be major contributing immunocompromised disease. Other diseases like hypertension, chronic kidney diseases, hypothyroidism, etc., were also attributed as an immunocompromised disease causing increased number of covid associated mucormycosis cases. We found out that total number of patients alive after taking only antifungal drug treatment were 25 in number, whereas total number of patients alive when antifungal drugs were combined with surgical intervention were 428 which was significantly higher. Conclusion: Our systematic review concluded that surgical debridement should be performed whenever feasible in parallel to antifungal treatment in order to reduce the mortality rate of COVID-19 associated rhino-orbito-cerebral mucormycosis patients.

Mucormycosis, Covid -19 & Diabetes "THE TROUBLESOME THREESOME"

Background: Covid-19 infection time and again has been causing major morbidities and mortalities. Increased vulnerability of Covid-19 recovered patients was seen towards mucormycosis infection. Mucormycosisis is an aggressive, angioinvasive fungal disease caued by fungi of order Mucorales. This increase in cases may be attributed to a weakened immune system, pre-existing comorbidities such as diabetes, overzealous use of steroids. We conducted a study on 25 cases admitted in mucor ward in a tertiary care setting to highlight this association and focusing on possible causes so that we can be prepared to handle any such catastrophe in future in a better way. Methods and Results: We did a retrospective study on 25 cases admitted in a tertiary care center catering to large population of Covid -19 patients with varying severity.Covid-19 associated mucormycosis(CAM) was found to be more common in males(76%).Diabetes mellitus was the most common underlying condition(72%).68% patients had received steroids and antibiotics, 28% patients had history of receiving Oxygen. In CAM predominant presentation was rhino-orbital mucormycosis. Unilateral orbit involvement was seen in (88%) cases. Conclusion(s): As severe acute respiratory syndrome coronavirus-2 is highly susceptible to mutations and is causingseries of waves, its association with opportunistic fungal infection is a serious concern. Incidences of mucormycosis were increased in Covid-19 patients due to immune modulation and coexistence of immunosuppressive conditions such as diabetes. Concurrent glucocorticoid therapy further heightens the risk. Early diagnosis and prompt intervention can help improve outcome. Copyright © 2023 Ubiquity Press. All rights reserved.

Stroke in patients with COVID associated Mucormycosis: A Report of Two Cases

Mucormycosis is a rare and invasive fungal disease with potentially fatal outcome. It most commonly affects patients with compromised immunity, especiallly those with poorly controlled diabetes. The incidence of mucormycosis has increased after the COVID-19 pandemic and both COVID-19 and mucormycosis are associated with an increased incidence of stroke. We present a report of two cases of COVID associated mucormycosis who had stroke. A 50-year-old patient with uncontrolled diabetes developed swelling of left eye and face ultimately leading to complete ophthalmoplegia of left eye. Imaging studies of brain revealed infarcts. MRI/MRA brain showed left internal carotid artery thrombosis, cavernous sinus thrombosis and a brain abscess in left temporal lobe. A second patient was a 65-year-old diabetic and hypertensive male who had COVID and then developed right MCA territory infarct and right sided cavernous sinus thrombosis. Diagnostic nasal endoscopy and biopsy was suggestive of mucormycosis in both the cases. Both these cases were managed with combination of tight glycemic control, antifungal therapy, and surgery. Clinicians should be aware of the association of stroke with COVID and COVID associated mucormycosis (CAM). Copyright © 2022 International Medical Sciences Academy. All rights reserved.

Is mucormycosis the end? A comprehensive management of orbit in COVID associated rhino-orbital-cerebral mucormycosis: preserving the salvageable.

BACKGROUND: Rhino-orbital-cerebral mucor mycosis (ROCM) is a relatively rare opportunistic infection caused by the Mucorales species. While ROCM suggests involvement of the paranasal sinuses, orbit and brain ROM (rhino-orbital-Mucormycosis) stands for the fungal invasion in sinuses and orbit sans cerebral involvement. In India with the outbreak of the second COVID wave and the delta variant of the virus, there has been a steep increase in this opportunistic fulminant fungal infection, named COVID-associated Mucor mycosis (CAM). The most critical question in orbital management is when to go ahead with an exenteration. Our study aims to design a pertinent minimal invasive surgical protocol for surgeons to manage such cases based on our surgical experience and mitigate the need for exenteration and save the eyes wherever possible. METHODS: The study is a retrospective analysis of patients of ROM with and without brain involvement, who underwent minimal surgical management between March 2021 to March 2022 along with their follow-up. RESULTS: There were 184 eyes of 148 patients diagnosed with CAM. The mean age was 51.7 years with a male predominance of 103 (70%). All patients developed ROM following the COVID-19 infection and the duration between diagnosis of COVID-19 and ROM was 36 ± 23 days. 18 cases (12%) were bilateral. 76 eyes (41%) had no vision at the presentation. Imaging revealed paranasal sinus involvement (100%), orbital apex involvement (61%), cavernous sinus involvement (53%), and central nervous system (CNS) involvement (47%). All the patients (100%) were treated with systemic Liposomal amphotericin-B and sinus debridement. Endoscopic debridement of the orbital disease was performed in 45 (30.4%) cases, 15(8.1%) eyes underwent exenteration and were later rehabilitated with a customized ocular prosthesis, 103 (56%) eyes underwent transcutaneous retrobulbar amphotericin-B. At a mean follow-up of 13.1 months; the complete resolution was seen in 25 (17%) cases, the residual stable lesion was seen in 77(52%) of the cases and new lesions were developed in 13(9%) of the cases. Mortality was seen in 33 (22%) patients and all of them had CNS involvement. CONCLUSIONS: Systemic and protocol-based management can save the life and salvage the eyes.

Mucormycosis, Covid -19 & Diabetes "THE TROUBLESOME THREESOME"

Background: Covid-19 infection time and again has been causing major morbidities and mortalities. Increased vulnerability of Covid-19 recovered patients was seen towards mucormycosis infection. Mucormycosisis is an aggressive, angioinvasive fungal disease caued by fungi of order Mucorales. This increase in cases may be attributed to a weakened immune system, pre-existing comorbidities such as diabetes, overzealous use of steroids. We conducted a study on 25 cases admitted in mucor ward in a tertiary care setting to highlight this association and focusing on possible causes so that we can be prepared to handle any such catastrophe in future in a better way. Methods and Results: We did a retrospective study on 25 cases admitted in a tertiary care center catering to large population of Covid -19 patients with varying severity.Covid-19 associated mucormycosis(CAM) was found to be more common in males(76%).Diabetes mellitus was the most common underlying condition(72%).68% patients had received steroids and antibiotics, 28% patients had history of receiving Oxygen. In CAM predominant presentation was rhino-orbital mucormycosis. Unilateral orbit involvement was seen in (88%) cases. Conclusion(s): As severe acute respiratory syndrome coronavirus-2 is highly susceptible to mutations and is causingseries of waves, its association with opportunistic fungal infection is a serious concern. Incidences of mucormycosis were increased in Covid-19 patients due to immune modulation and coexistence of immunosuppressive conditions such as diabetes. Concurrent glucocorticoid therapy further heightens the risk. Early diagnosis and prompt intervention can help improve outcome. Copyright © 2023 Ubiquity Press. All rights reserved.

Clinical Spectrum of Mucormycosis among COVID-19 Patients Attending Tertiary Health Care Facility: Hospital based Descriptive Study

Diabetes Mellitus predisposes patients to invasive fungal infections. There has been a recent surge of Mucormycosis with COVID 19 infection particularly in patients with diabetes. This study aims to study the clinical spectrum of CAM (COVID-associated Mucormycosis) with diabetes and subsequent outcomes. Material(s) and Method(s): Descriptive study was conducted among the patients attending Ophthalmology OPD in a Tertiary Care Centre in Telangana with COVID Associated Mucormycosis(CAM) from March 2021 to June 2021. Result(s): Among 200 patients who attended OPD with CAM, Diabetes Mellitus was the most common co-morbidity. The majority of the patients had poor glycaemic control with a mean HbA1c of 9.06%. Pre-existing diabetes mellitus (DM) was present in 84% of cases. Out of the total study population, 89% had prior exposure to high dose corticosteroids. Conclusion(s): The disease has surged in COVID 19 pandemic due to uncontrolled diabetes and improper corticosteroid use. Copyright © 2023, Institute of Medico-legal Publication. All rights reserved.

Pathogenesis and Pathology of COVID-Associated Mucormycosis: What Is New and Why.

Purpose of Review: There is global increase in the incidence of mucormycosis. However, a sudden increase in the COVID-associated mucormycosis (CAM) was noted, particularly in India, during the second wave of the COVID-19 pandemic. The interplay of factors involved in the pathogenesis is complex. In this review, the influence of pre-existing disease, exaggerated risk factors, altered milieu due to COVID-19 itself and the consequences of its treatment on the host pathogen interactions leading to the disease and morphology of the fungus will be highlighted. Recent Findings: Hyperglycemia, acidosis, available free iron, lowered host defenses, and the fungal virulence factors promote the growth of Mucorales. There is a high background prevalence of diabetes mellitus (DM) in India. Uncontrolled or undiagnosed DM, COVID-19 itself, and inappropriate administration of corticosteroids in high doses and for prolonged periods result in hyperglycemia. Diabetic ketoacidosis (DKA) and metabolic acidosis due to hypoxia or renal failure contribute to acidic pH and dissociate bound iron from serum proteins. The host defenses are lowered due to COVID-19-induced immune dysregulation, hyperglycemia itself, and administration of corticosteroids and immune suppressants for the treatment of COVID-19. The altered metabolic milieu in the local microenvironment of nose and paranasal sinuses (PNS) promotes specific interaction of glucose-regulated protein-78 (GRP-78) on host cells with spore coat protein homologue (CotH 3) on Mucorales resulting in rhino-orbito-cerebral mucormycosis (ROCM) as the predominant clinical form in CAM. The pathology is extensive soft tissue involvement with angioinvasion and perineural invasion. Melanized hyphae and sporangia were seen on histopathology, which is unique to CAM. While many factors favor the growth of Mucorales in CAM, hyperglycemia, hyperferritinemia, and administration of hyperbaric oxygen result in reactive oxygen species (ROS) and inadequate humidification results in dehydration. Melanization is possibly the adaptive and protective mechanism of Mucorales to escape the unfavorable conditions due to the treatment of COVID-19. Summary: High background prevalence of DM, inappropriate administration of corticosteroids and immune dysregulation due to COVID-19 favor the growth of Mucorales in CAM. Melanization of Mucorales hyphae and sporangia on histopathology probably represent adaptive and protective mechanism due to the treatment with hyperbaric oxygen with inadequate humidification as well as the metabolic alterations.

Preliminary Experience in Post-COVID-19 Mycoses: A Pathologist's Perspective.

Background Coronavirus disease is caused by the severe acute respiratory syndrome coronavirus-19. Because of co-morbidities and indiscriminate use of steroids and antibiotics, the incidence of opportunistic fungal infections has increased in COVID-affected individuals. Aims and objectives The aim of the study is to analyze the various tissue reaction patterns of COVID-19-associated mucormycosis in the surgical debridement specimens using routine hematoxylin and eosin (H&E) stain and special stains like periodic acid-Schiff (PAS), Grocott-Gomori's methenamine silver (GMS), Masson trichrome (MT) and Prussian blue (PB), and to understand the pathogenesis of COVID-19 sequelae. Materials and methods This retrospective observational study was conducted after the approval from the Institute Human Ethical Committee (IHEC) on 45 tissue samples of COVID-associated mucormycosis using routine H&E and histochemical stains such as PAS, GMS, MT, and PB. Detailed demographic profiles, clinical information, radiological findings, and relevant microbiological data in available cases, like reports on potassium hydroxide (KOH) mount preparation, and fungal culture reports on Saboraud's Dextrose Agar (SDA) medium were collected. The different histomorphological tissue reaction patterns were observed and analyzed. Results All the surgical debridement specimens from post-COVID cases had histomorphology of mucormycosis displaying broad, aseptate, ribbon-like fungal hyphae with right-angle branching (45/45). Six of the 45 cases also reveal thin, narrow septate, acute angle branching hyphae, indicating co-existing Aspergillosis (6/45). The histological tissue reaction patterns observed were categorized as extensive tissue necrosis (100%), vascular proliferation (82%), angioinvasion (58%), giant cell reaction (53%), fibrin thrombi (47%), septic thrombi and angiodestruction (40%), fungal osteomyelitis (33%), necrotizing granulomas (31%). Conclusion This study infers that post-COVID-19 associated mucormycosis, alterations in the local tissue microenvironment are found to have a favorable effect on colonizing fungi and result in destructive tissue reactions such as angioinvasion, angiodestruction, necrosis, necrotizing granulomas, suppurative inflammation, and iron pigment deposition. The spectrum of morphological changes reflects the host's immune status.

MR imaging spectrum in COVID associated Rhino-Orbito-Cerebral mucormycosis with special emphasis on intracranial disease and impact on patient prognosis.

In the wake of the ongoing Coronavirus Disease 2019 (COVID-19) pandemic, a new epidemic of COVID associated mucormycosis (CAM) emerged in India. Early diagnosis and prompt treatment of this deadly disease are of paramount importance in improving patient survival. MRI is the cornerstone of diagnosis of early extrasinus disease, particularly intracranial complications which have traditionally been associated with a high mortality rate. In this review, we depict the sinonasal, perisinus, orbital and intracranial involvement in CAM. Special emphasis is laid on intracranial disease which is categorized into vascular, parenchymal, meningeal, bony involvement and perineural spread. Vascular complications are the most common form of intracranial involvement. Some unusual yet interesting imaging findings such as nerve abscesses involving the optic, trigeminal and mandibular nerves and long segment vasculitis of the internal carotid artery extending till its cervical segment are also illustrated. In our experience, patient outcome in CAM (survival rate of 88.5%) was better compared to the pre-pandemic era. Presence of intracranial disease also did not affect prognosis as poorly as traditionally expected (survival rate of 82.8%). Involvement of brain parenchyma was the only subset of intracranial involvement that was associated with higher mortality (p value 0.016). The aim of this review is to familiarise the reader with the MR imaging spectrum of CAM with special focus on intracranial complications and a brief account of their impact on patient prognosis in our experience.

COVID-19-Associated Pulmonary Fungal Infection among Pediatric Cancer Patients, a Single Center Experience.

Patients with COVID-19 are at risk of developing secondary complications such as invasive pulmonary aspergillosis and mucormycosis. This is a retrospective study including all cancer children diagnosed with COVID-19-associated pulmonary fungal infection (CAPFI) during the period 2020-2021. A total of 200 patients were diagnosed with COVID-19, out of which 21 (10%) patients were diagnosed with CAPFI, 19 patients (90%) with COVID-aspergillosis (CAPA), and 2 (10%) patients with COVID-mucormycosis (CAM). Patients with CAPFI were classified using the "2020 ECMM/ISHAM consensus criteria"; proven in 2 (10%) patients, probable in 12 (57%), and possible in 7 (33%) patients. Although the hematological malignancy patients were already on antifungal prophylaxis, breakthrough fungal infection was reported in 16/21 (75%), 14 (65%) patients had CAPA while on echinocandin prophylaxis, while 2 (10%) patients had CAM while on voriconazole prophylaxis. Overall mortality was reported in 8 patients (38%) while CAPFI-attributable mortality was reported in 4 patients (20%). In conclusion, clinicians caring for pediatric cancer patients with COVID-19 should consider invasive pulmonary fungal infection, even if they are on antifungal prophylaxis, especially with worsening of the clinical chest condition. A better understanding of risk factors for adverse outcomes may improve clinical management in these patients.